Comprehensive Health History Assessment: Insights for Young Adult Nursing Students

Abstract

Health History Assessment and Reflection [Name] [University] NR302 Health Assessment [Name] 02/07/2021 Health History Assessment and Reflection Demographic The patient's demographic information provides an overview of the expected health issues they may encounter and the care needs they could expect. For instance, “the age and gender of the individual could determine the approach of care adopted by nurses at health facilities.” (Kaakinen et al., 2018.) Anna Do, a 22-year-old nursing student, was interviewed. At the interview time, she was single and had visited the virtual WebEx for purposes associated with an annual physical examination. Perception of Health At the time of the virtual visit, the patient demonstrated constant migraines that had affected her comfort. She has trouble sleeping and indicated that she experienced stress occasionally. Anna Do had visited the facility for a physical examination, and it has been a year since she had her previous exam. She did physical exercise six times a week and did not demonstrate symptoms of reproductive health problems. Past Medical History The patient's past medical history is critical in dealing with her present conditions and providing the appropriate medication. The interviewee does not have a terminal illness or any identified allergic reaction to drugs or medicines at the hospital. She reported having no drug abuse problems such as challenges or engaging in risky behaviour after consumption. Ms Do demonstrated that the patient was sexually active and did not have intimate relationships such as violence. While she was not on a physically recommended diet, she reported being a pescatarian, a diet that excludes meat but includes fish. Family Medical History “By examining the medical history of a patient’s family, nurses can offer better care and determine the issues that could affect the individual” (Kaakinen et al., 2018). The mother and the interviewee's father are both healthy, and we're 55 years old each. She reported that her 27-year-old brother was healthy as well. Ms Do’s grandparents were above 85 years old and had chronic illnesses. The maternal grandmother had respiratory health issues while the grandfather lung cancer. Additionally, her paternal grandmother had thyroid cancer, and the grandfather had a heart attack. Review of Systems Body systems may indicate the possibility of current and future health issues likely to affect patients at different ages in their lives. During the assessment, it was noted that most of the patient's health systems had not experienced any serious issue in the past. However, she indicated skin/hair/nails and head/neck health problems before the current interview. Developmental Considerations At the time of the interview, the patient was in her early 20s and living with family members. She demonstrated signs of belonging to a supportive family determined to meet her immediate and long-term needs at home. Additionally, the patient was attending nursing school at the time of the interview. There were no alarming issues concerning her developmental health and the impact on care needs. Cultural Considerations During care, the cultural background informs the nurses that sensitive aspects of care arise in different communities. The interviewee was Vietnamese, and her Asian culture could affect the care nurses provided to her and their interaction with her family members. “In the Asian culture, healthcare is significantly oriented towards family members and group support.” (Shahin et al., 2019). When caring for the patient, it would be critical to consider family members' involvement whose input is deemed necessary in meeting the patient’s needs. Psychological Considerations While the interviewee reported having had incidents of stress, she was emotionally and mentally healthy. She had not had a major incident of depression, drug or alcohol abuse in the past. Her drinking was described as once every other week, indicating that she did not have an addiction. Additionally, the interviewee was observed receiving emotional support since she resided alongside other individuals in her residence. Collaborative Resources “Developments in healthcare have focused on the measures through which care providers could work towards meeting the needs of their patients. Information sharing among nurses is critical in facilitating the provision of quality care in healthcare organizations” (Nibbelink, & Brewer, 2018). The interview demonstrates that through the information provided by a patient, it is possible to focus on their immediate and long-term needs. Anna Do provided critical information on her past experiences concerning healthcare procedures, including vaccinations, that could shed light on her current health state. Physical Examination: Objective Data. The four steps of physical examination involve inspection, feeling(palpation), tapping to determine resonance characteristics (Percussion), and listening(auscultation). HEENT physical examination involves identifying the basic components of the head, eye, ears, nose, and throat, their anatomic landmarks and record basic findings. The student nurse was examined to check HEET disorders and their signs and symptoms. It also involved inspection of the head, checking the scalp size, symmetry and deformity and palpation to check for tenderness, deformity, hair quantity and distribution, and presence of lumps. The neck was examined, checking the lymph nodes and trachea deviation. The eyes were checked on the eyebrows eyelids to check on hair loss, swelling, and redness. The ears were examined to check lumps and deformities on the posterior and anterior and pinna tenderness. The external nares of the nose were reviewed on symmetry and deformation and internal nares on septal deviation. The thyroid glands were checked on tenderness, size, and mobility. The respiratory system was examined based on the respiratory sounds (rales, rhonchi, stridor, and wheezing). The student nurses’ cardiovascular system was examined through cardiac examination, heart sounds, auscultation of the heart and carotid bruits, cervical venous hums and the arterial pulse. The neurological system was examined by checking the mental status, reflexes, nerves, motor function, and sensory examination. The gastrointestinal system was identified using an X-ray to examine the oesophagus, stomach, small intestines, large intestines, and rectum. The musculoskeletal system's common methods are inspection and palpation to assess muscle strength and flexibility, soft tissues, and gaits. The peripheral vascular system was examined by palpation of the femoral pulse, popliteal pulse, posterior tibial pulse, the femoral artery's auscultation, and the popliteal artery. Anna was found with depression and anxiety after physical examination. She was restless and fatigue, experienced muscle tension, gastrointestinal problems, and frequent allergies. Needs Assessment One of the health educations needs of the individual is fitness and exercise. According to (Ho et al. 2020), Physical fitness, a...